OMB No. 0730-0014 DEPENDENCY STATEMENT - PARENT …

1 DEPENDENCY STATEMENT - PARENTPLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO YOUR LOCAL SERVING No. 0730-0014 OMB approval expires Nov 30, 2010 CONTROL NUMBERPRIVACY ACT STATEMENTAUTHORITY: 93-64; 37 , Chapter 7, Section 403; 9397 (SSN); and DoDFMR , Vol. 7a, Chapter PURPOSE(S): The information will be used to determine the relationship and DEPENDENCY of the claimed dependentsand determine the member's entitlement to authorized USE(S): In addition to those disclosures generally permitted under 5 552a(b) of the Privacy Act, these records orinformation contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 552a(b)(3) asfollows: The DoD "Blanket Routine Uses" published at the beginning of the DoD compilation of systems of records notices : Voluntary; however, failure to provide this information will result in a suspension of the dependent entitlement until themilitary member provides the required The member must complete Items 1 and 2, and sign and date the form.

2 PARENT or PARENT (s) representative (if PARENT is unable tocomplete the form due to health or physical disability) must complete Items 3 through 12, sign and date the form, and have the formnotarized. If a representative completes the form for the PARENT (s), include in the Remarks section the name of the individual, therelationship, and the reason the form was not completed by PARENT (s). If the member is deceased, information furnished must reflectthe 12 months prior to member's : Answer all questions. If any question does not apply, write "NOT APPLICABLE" or "N/A" in that block. Use the Remarks section whenrequired. Incomplete answers will delay final action on the application. Verification of all income is required. Proof of member's contribution isrequired when applying for Basic Allowance for Housing (BAH). PARENT must be more than 50% dependent upon ENTITLEMENTS REQUESTED (X and complete as applicable)a.

3 TYPEBAHTRAVEL ALLOWANCEb. FIRST APPLICATION?YES (If No, give date of last application)NO (YYYYMMDD)c. LAST APPLICATION WASAPPROVEDDISAPPROVED2. MEMBER INFORMATIONa. NAME (Last, First, Middle Initial)b. SSNc. RANKd. STATUS (X and complete as applicable)ACTIVE DUTYRETIREDNATIONAL GUARDRESERVEDECEASED (Date of death) (YYYYMMDD)OTHER (Specify)e. complete RESIDENCE ADDRESS (Street, Apartment Number, City, State, ZIP Code)f. complete MILITARY ADDRESS (Include assignment: squadron and base)g. TELEPHONE NUMBERS (Include DSN or Area Code)(1) WORK(2) HOMEi. MARITAL STATUS (X one)SINGLEMARRIEDSEPARATEDDIVORCEDWIDOWE D3. PARENT (S) INFORMATION(1) NAME (Last, First, Middle Initial)(2) SSN(3) DATE OF BIRTH (YYYYMMDD)DD FORM 137-3, JAN 2008 PREVIOUS EDITION IS OBSOLETE. Page 1 of 5 PagesAdobe Professional CORPSNAVYAIR FORCEUSIP CARD(4) RELATIONSHIPa.

4 (1) NAME (Last, First, Middle Initial)(2) SSN(3) DATE OF BIRTH (YYYYMMDD)(4) E-MAIL ADDRESSThe public reporting burden for this collection of information is estimated to average hours per response, including the time for reviewing instructions, searching existing data sources, gatheringand maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 1155 Defense Pentagon, Washington, DC 20301-1155 ( 0730-0014 ). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

5 DD FORM 137-3, JAN 2008 Page 2 of 5 Pages4. PARENT 'S RESIDENCEa. TYPE OF RESIDENCE (X and complete as applicable)HOME OR APARTMENT OF FRIEND OR RELATIVE (State relationship)HOSPITAL OR INSTITUTIONHOME OR APARTMENT OF PARENTHOME OR APARTMENT OF MEMBER(Date began residing with member)OTHER (Explain)b. OWNER OF RESIDENCE(1) NAME (Last, First, Middle Initial)(2) ADDRESS (Street, Apartment Number, City, State, ZIP Code)c. IS RESIDENCE SUBSIDIZED HOUSING?YESNOd. DATE PARENT STARTED LIVING AT CURRENT ADDRESS (YYYYMMDD)e. IS CURRENT ADDRESS PARENT 'S PERMANENT ADDRESS?YES (If No, explain where else PARENT lives and number of months there each year.)NOc. MARITAL STATUS (X one)MARRIEDSINGLEWIDOWEDg. DOES ANY OTHER CHILD CLAIM PARENT FOR BAH, TRAVEL ALLOWANCE, OR USIP CARD? (If Yes, give child's name, SSN, and branch of service.)YESNODIVORCED3. PARENT (S) INFORMATION (Continued) (7) PRESENT OCCUPATION OR BUSINESS(8) NAME AND ADDRESS OF EMPLOYER (If unemployed, state reason, date unemployment began, and date employment is expected to resume.)

6 (7) PRESENT OCCUPATION OR BUSINESS(8) NAME AND ADDRESS OF EMPLOYER (If unemployed, state reason, date unemployment began, and date employment is expected to resume.)LIVING APART UNDER LEGALSEPARATIONd. IF SPOUSE IS DECEASED OR LEGALLY SEPARATED FROM PARENT , GIVE DATE OF DEATH, DIVORCE, OR SEPARATION (YYYYMMDD)e. IF PARENT AND SPOUSE LIVE APART OR SPOUSE DOES NOT SUPPORT PARENT , GIVE REASON:f. CHILDREN (List all PARENT 's living children regardless of age. Show the average monthly contribution to PARENT from each child. Continue in Remarks section if more space is needed.)(1) NAME(Last, First, Middle Initial)(2) SSN(Service Members Only)(3) BRANCH OF SERVICE(If on Active Duty)(4) MONTHLY CONTRIBUTIONTO PARENT (5) complete ADDRESS (Street, Apartment Number, City, State, ZIP Code)(6) TELEPHONE NUMBER (Include Area Code)(5) complete ADDRESS (Street, Apartment Number, City, State, ZIP Code)(6) TELEPHONE NUMBER (Include Area Code)DD FORM 137-3, JAN 2008 Page 3 of 5 Pages7.

7 PARENT 'S PERSONAL EXPENSES List personal expenses for PARENT , PARENT 's spouse, and their unmarried minor children who are not fully employed and who live in the samehousehold. Do not list personal expenses for the member, his or her immediate family, or any other person. List all of the PARENT 's personal expensesregardless of who is paying for (1)PRESENT MONTHLYEXPENSE(2)TOTAL EXPENSE FORPAST 12 MONTHSITEM(1)PRESENT MONTHLYEXPENSE(2)TOTAL EXPENSE FORPAST 12 MONTHSa. CLOTHINGb. LAUNDRY AND DRY CLEANINGc. MEDICAL (Do not include expenses paid by insurance, welfare, or Medicare)d. VALUE OF USIP CARD (Verification of amount is required)e. PERSONAL INSURANCE (Specify) f. PERSONAL TAXES (Specify)g. PRIVATE AUTO PAYMENTS (If auto is registered in PARENT 's name)h. MONTHLY TRANSPORTA- TION PAYMENTS (Include gas, oil, insurance, repairs, and public transportation)i.

8 SCHOOL EXPENSES (Itemize)j. OTHER EXPENSES (Itemize)5. PERSONS LIVING IN HOUSEHOLD WITH PARENTa. NAME (Last, First, Middle Initial)c. AGEd. MARRIED (X)YESNOe. EMPLOYEDHOURS PER WEEKNO (X)b. RELATIONSHIPTO PARENTf. MONTHLYCONTRIBUTION TOPARENT6. HOUSEHOLD EXPENSES List the household expenses for all persons living in the home. If expense was one-time only, such as purchase of a new chair, do not show this asa monthly expense; list it as an expense for the past 12 months. If PARENT resides in the member's household or in a dwelling owned by the member,use Fair Rental Value (FRV) for dwelling. If PARENT does not reside in member's household or in a dwelling owned by member, list actual mortgage,rent, or FRV if dwelling is mortgage-free. If FRV is used, give a brief explanation of how Fair Rental Value was obtained using the Remarks section. However, if PARENT resides in and owns home mortgage free, enter "None" in mortgage/rent/FRV block.

9 FAIR RENTAL VALUE (FRV): FRV is a single monthly sum for the entire dwelling where the PARENT lives. This sum is an amount the owner canreasonably expect to receive from a stranger to rent the dwelling. FRV will not include food, utilities, furniture, and home repairs, which are (1)PRESENT MONTHLYEXPENSE(2)TOTAL EXPENSE FORPAST 12 MONTHSITEM(1)PRESENT MONTHLYEXPENSE(2)TOTAL EXPENSE FORPAST 12 MONTHSa. (X one)MORTGAGE (Specifyamount of tax andinsurance if applicable)RENTFRVb. FOODc. UTILITIES (Heat, power, water, and telephone)d. FURNITURE AND APPLIANCESe. REPAIRS ON HOMEf. OTHER (Itemize in Remarks section) List all persons who live in the household, including claimed PARENT . If employed, show hours per week worked. Continue in Remarks if morespace is DD FORM 137-3, JAN 2008 Page 4 of 5 Pages8. PARENT 'S ASSETS9. PARENT 'S INCOME List all assets such as real estate (including home), personal property, farm and/or business equipment, automobiles, trucks, cash, savings of anytype, stocks, bonds, etc.

10 , whether owned separately by PARENT , jointly with spouse, or jointly by PARENT or spouse with another person. Assets must belisted even though PARENT may not be using the income earned by these assets, but is allowing the interest of dividends to DESCRIPTION(1) PRESENTMONTHLYINCOME(2) TOTAL INCOMEFOR PAST 12 MONTHSa. WAGES, SALARIES, TIPS, OR OTHER CASH GRATUITIESj. SOCIAL SECURITY PAYMENTS, DISABILITY OR REGULAR (Specify type) b. INTEREST ON INVESTMENTS, BONDS, SAVINGS, TRUST FUNDS, SUPPLEMENTAL SECURITY INCOME (SSI)c. INSURANCE OR PUBLIC/ GOVERNMENT PENSION PAYMENTS, UNEMPLOYMENT OR DISABILITY COMPENSATION (Specify type) l. VETERANS ADMINISTRATION PAYMENTS (Specify type) SOURCE(1) PRESENTMONTHLYINCOME(2) TOTAL INCOMEFOR PAST 12 MONTHSf. CONTRIBUTIONS FROM PERSONS OTHER THAN MEMBERg. TAX REFUNDS (Specify) h. OTHER (Specify) d.